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In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status.
Aetna Inc. is an American managed health care company that sells traditional and consumer directed health care insurance and related services, such as medical, pharmaceutical, dental, behavioral health, long-term care, and disability plans, primarily through employer-paid insurance and benefit programs, and through Medicare. Since November 28, 2018, the company has been a subsidiary of CVS Health.
Kaiser Permanente is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser Permanente is made up of three distinct but interdependent groups of entities: the Kaiser Foundation Health Plan, Inc. (KFHP) and its regional operating subsidiaries; Kaiser Foundation Hospitals; and the regional Permanente Medical Groups. As of 2023, Kaiser Permanente operates in eight states and the District of Columbia, and is the largest managed care organization in the United States.
The Cigna Group is a for-profit American multinational managed healthcare and insurance company based in Bloomfield, Connecticut. Its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and services, the majority of which are offered through employers and other groups. Cigna is incorporated in Delaware.
Humana Inc. is a for-profit American health insurance company based in Louisville, Kentucky. In 2023, the company ranked 42 on the Fortune 500 list, which made it the highest ranked company based in Kentucky. It is the fourth largest health insurance provider in the U.S.
Sicko is a 2007 American political documentary film by filmmaker Michael Moore. Investigating health care in the United States, the film focuses on the country's health insurance and the pharmaceutical industry. Moore compares the for-profit non-universal U.S. system with the non-profit universal health care systems of Canada, the United Kingdom, France and Cuba.
The term managed care or managed healthcare is used in the United States to describe a group of activities intended to reduce the cost of providing health care and providing American health insurance while improving the quality of that care. It has become the predominant system of delivering and receiving American health care since its implementation in the early 1980s, and has been largely unaffected by the Affordable Care Act of 2010.
...intended to reduce unnecessary health care costs through a variety of mechanisms, including: economic incentives for physicians and patients to select less costly forms of care; programs for reviewing the medical necessity of specific services; increased beneficiary cost sharing; controls on inpatient admissions and lengths of stay; the establishment of cost-sharing incentives for outpatient surgery; selective contracting with health care providers; and the intensive management of high-cost health care cases. The programs may be provided in a variety of settings, such as Health Maintenance Organizations and Preferred Provider Organizations.
In U.S. health insurance, a preferred provider organization (PPO), sometimes referred to as a participating provider organization or preferred provider option, is a managed care organization of medical doctors, hospitals, and other health care providers who have agreed with an insurer or a third-party administrator to provide health care at reduced rates to the insurer's or administrator's clients.
UnitedHealth Group Incorporated is an American multinational health insurance and services company based in Minnetonka, Minnesota. Offering insurance products under UnitedHealthcare, and health care services and care delivery aided by technology and data under Optum, it is the world's eleventh-largest company by revenue and the largest health care company by revenue.
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines.
AHIP is an American political advocacy and trade association of health insurance companies that offer coverage through the employer-provided, Medicare Advantage, Medicaid managed care, and individual markets.
Aetna Health Inc. v. Davila, 542 U.S. 200 (2004), was a United States Supreme Court case in which the Court limited the scope of the Texas Healthcare Liability Act (THCLA). The effective result of this decision was that the THCLA, which held Case Management and Utilization Review decisions by Managed Care entities like CIGNA and Aetna to a legal duty of care according to the laws of The State of Texas could not be enforced in the case of Health Benefit plans provided through private employers, because the Texas statute allowed compensatory or punitive damages to redress losses or deter future transgressions, which were not available under ERISA § 1132. The ruling still allows the State of Texas to enforce the THCLA in the case of Government-sponsored (Medicare, Medicaid, Federal, State, Municipal Employee, etc., Church-sponsored, or Individual Health Plan Policies, which are saved from preemption by ERISA. The history that allows these Private and Self-Pay Insurance to be saved dates to the "Interstate Commerce" power that was given the federal Government by the Supreme Court. ERISA, enacted in 1974, relied on the "Interstate Commerce" rule to allow federal jurisdiction over private employers, based on the need of private employers to follow a single set of paperwork and rules for pensions and other employee benefit plans where employers had employees in multiple states. Except for private employer plans, insurance can be regulated by the individual states, and Managed Care entities making medical decisions can be held accountable for those decisions if negligence is involved, as allowed by the Texas Healthcare Liability Act.
In the United States, health insurance helps pay for medical expenses through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include "health coverage", "health care coverage", and "health benefits". In a more technical sense, the term "health insurance" is used to describe any form of insurance providing protection against the costs of medical services. This usage includes both private insurance programs and social insurance programs such as Medicare, which pools resources and spreads the financial risk associated with major medical expenses across the entire population to protect everyone, as well as social welfare programs like Medicaid and the Children's Health Insurance Program, which both provide assistance to people who cannot afford health coverage.
Medicare Advantage is a capitated program for providing Medicare benefits in the United States. Under Part C, Medicare pays a sponsor a fixed payment. The sponsor then pays for the health care expenses of enrollees. Sponsors are allowed to vary the benefits from those provided by Medicare's Parts A and B as long as they provide the actuarial equivalent of those programs. The sponsors vary from primarily integrated health delivery systems to unions to other types of non profit charities to insurance companies. The largest sponsor is a hybrid: the non profit charity AARP using UnitedHealth.
The Council for Affordable Quality Healthcare, Inc. (CAQH) is a non-profit organization incorporated in California as a mutual benefit corporation. It was first incorporated under the name Coalition for Affordable, Quality Healthcare, Inc., and then renamed the Council for Affordable Quality Healthcare, Inc. on August 8, 2002. It is based in Washington, D.C. Previously a 501(c)(6) tax-exempt organization, CAQH changed its tax status in 2016, although it remains a non-profit.
CareSource is a nonprofit that began as a managed health care plan serving Medicaid members in Ohio. Today, it provides public health care programs including Medicaid, Medicare, and Marketplace. The company is headquartered in Dayton, Ohio. It is the largest Medicaid plan in Ohio and is second largest in the United States.
Wendell Potter is an American advocate for health insurance payment reform, New York Times bestselling author, and former health insurance industry communications director. A critic of HMOs and the tactics used by health insurers, Potter is also a leading national advocate for major reforms of the health insurance industry, including Medicare for All and universal health care.
Capitation is a payment arrangement for health care service providers. It pays a set amount for each enrolled person assigned to them, per period of time, whether or not that person seeks care. The amount of remuneration is based on the average expected health care utilization of that patient, with payment for patients generally varying by age and health status.
Paul Murdock Ellwood Jr. was an American physician and a controversial figure in American health care. Often referred to as the "father of the health maintenance organization", he not only coined the term, he also played a role in bringing about structural changes to the American health care system to simultaneously control cost and promote health by replacing fee-for-service with prepaid, comprehensive care. The term "HMO" was coined by Ellwood in a January 1970 Fortune magazine article. More recently, he had advanced an agenda for monitoring health outcomes, so that patients, providers, and payers can make health care decisions based on real information about what treatments and providers are actually effective.
Miguel B. "Mike" Fernandez is an American health care industry businessman, investor, and philanthropist. He is the founder of MBF Healthcare Partners, a private equity firm founded in 2005 in Coral Gables, Florida. Fernandez is a major Republican donor.
References
- ↑ Koppelman, Alex (August 21, 2009). "New ad: Insurance companies have the death panels". Salon. Retrieved February 25, 2023.
- 1 2 Rovner, Julie (September 3, 2007). "'Sicko's' Peeno Sees Few Gains in Health Insurance". NPR. Retrieved February 25, 2023.
- ↑ Testimony of Linda Peeno, MD about Managed Care in the Healthcare Industry - May 30, 1996 Archived June 1, 2008, at the Wayback Machine
- ↑ Bell, Keaton (August 22, 2020). "Every Laura Dern Performance, Ranked". Vogue. Retrieved February 25, 2023.
- ↑ "Humana responds to Michael Moore's 'SiCKO'". Milwaukee Business Journal. June 28, 2007. Retrieved February 25, 2023.
